,,06-11,,,FORM CMS-1984-99,,,,3895 (Cont.) ,,ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99,,,,,,, ,,"TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS",,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,INTRODUCTION,,,, ,,,,,,,,, ,,This table identifies those data elements necessary to calculate a hospice cost report. It also identifies ,,,,,,, ,,"some figures from a completed cost report. These calculated fields (e.g., Worksheet B, column 7) are ",,,,,,, ,,needed to verify the mathematical accuracy of the raw data elements and to isolate differences between ,,,,,,, ,,the file submitted by the hospital complex and the report produced by the fiscal intermediary. Where an,,,,,,, ,,"adjustment is made, that record must be present in the electronic data file. For explanations of the",,,,,,, ,,"adjustment required, refer to the cost report instructions.",,,,,,, ,,,,,,,,, ,,"Table 3 ""Usage"" column is used to specify the format of each data item as follows:",,,,,,, ,,,,,,,,, ,,,,9," Numeric, greater than or equal to zero.",,,, ,,,,-9," Numeric, may be either greater than or less than zero.",,,, ,,,,9(x).9(y)," Numeric, greater than zero, with x or fewer significant",,,, ,,,,," digits to the left of the decimal point, a decimal point,",,,, ,,,,, and exactly y digits to the right of the decimal point.,,,, ,,,,X, Character.,,,, ,,,,,,,,, ,,Consistency in line numbering (and column numbering for general service cost centers) for each cost ,,,,,,, ,,center is essential. The sequence of some cost centers does change among worksheets. ,,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,,,,, ,,"Table 3 refers to the data elements needed from a standard cost report. When a standard line is subscripted,",,,,,,, ,,"the subscripted lines must be numbered sequentially with the first subline number displayed as ""01"" or ""1""",,,,,,, ,,"in field locations 14-15. It is unacceptable to format in series of 10, 20, or skip subline numbers (i.e., 01, ",,,,,,, ,,"03, except for skipping subline numbers for prior year cost center(s) deleted in the current period or initially",,,,,,, ,,created cost center(s) no longer in existence after cost finding). Exceptions are specified in this manual.,,,,,,, ,,"For ""Other (specify)"" lines, i.e. any other non cost center lines, all subscripted lines should be in",,,,,,, ,,"sequence and consecutively numbered beginning with subscripted subline ""01"". Automated systems",,,,,,, ,,should reorder these numbers where the provider skips or deletes a line number in the series.,,,,,,, ,,,,,,,,, ,,Drop all records with zero values from the file. Any record absent from a file is treated as if it were zero.,,,,,,, ,,,,,,,,, ,,All numeric values are presumed positive. Leading minus signs may only appear in data with values,,,,,,, ,,"less than zero which are specified in Table 3 with a usage of ""-9"". ",,,,,,, ,,,,,,,,, ,,Italic script within this table denotes adjustments which are not displayed in the print image or hard copy,,,,,,, ,,"of the cost report, but are contained in the ECR file.",,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,,,,, ,,Rev. 8,,,,,,,38-213 ,,3895 (Cont.),,,FORM CMS-1984-99,,,,06-11 ,,ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99,,,,,,, ,,"TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS",,,,,,, ,,,,,,,,, ,,,,,,,,FIELD, ,,,,DESCRIPTION,,LINE(S),COLUMN(S),SIZE,USAGE ,,,,,,,,, ,,,,,WORKSHEET S-1,,,, ,,,,,,,,, ,,Part I,,,,,,, ,,,Name of the hospice,,,1,1,36,X ,,,Address,,,1,2,36,X ,,,City,,,1,3,36,X ,,,State,,,1,4,2,X ,,,Zip Code,,,1,5,10,X ,,,County,,,2,1,36,X ,,,Date hospice began operation (mm/dd/yyyy),,,3,1,10,X ,,,Certification date (mm/dd/yyyy) for Title XVIII,,,4,1,10,X ,,,Certification date (mm/dd/yyy) for Title XIX,,,4,2,10,X ,,,Cost reporting period beginning date (mm/dd/yyyy),,,5,1,10,X ,,,Cost reporting period ending date (mm/dd/yyyy),,,5,2,10,X ,,,Provider number (xxxxxx),,,6,1,6,X ,,,National Provider Identifier,,,6.01,1,10,X ,,,Type of control (See Table 3B.),,,7,1,2,9 ,,,,,,,,, ,,Part II - Enrollment Days,,,,,,, ,, Continuous Home Care,,,,8,1-5,11,9 ,, Routine Home Care,,,,9,1-5,11,9 ,, Inpatient Respite Care,,,,10,1-5,11,9 ,, Inpatient General Care,,,,11,1-5,11,9 ,,Total Hospice days,,,,12,1-6,11,9 ,,,,,,,,, ,,Part III - Census Data,,,,,,, ,, Number of Patients Receiving Hospice Care,,,,13,1-6,11,9 ,, Unduplicated Continuous Medicare Hours,,,,14,1 & 3,11,9(8).99 ,, Average Length of Stay (line5/line 6),,,,15,1-6,11,9(8).99 ,, Unduplicated Census Count,,,,16,1-6,11,9 ,, If the hospice componentized (or fragmented) it’s administrative,,,,,,, ,," and general service cost, indicate whether option one or",,,,,,, ,, or two is being utilized. (See instructions),,,,17,1,1,9 ,, Are there any related organization or home office costs as defined ,,,,,,, ,," in CMS Pub. 15-I, chapter 10?",,,,18,1,1,X ,," If yes, enter home office chain number, if applicable. ",,,,18,2,6,X ,,,,,,,,, ,,Part IV - Inpatient General Care Costs,,,,,,, ,, Drug costs,,,,19,1,11,9 ,, Durable medical equipment/oxygen costs,,,,19,2,11,9 ,, Medcial supply costs,,,,19,3,11,9 ,,,,,,,,, ,,,,,WORKSHEET A,,,, ,,,,,,,,, ,,Transportation,,,,"1-6,10-11, 15-25,",,, ,,,,,,"30-39, 50-53",3,11,9 ,,Other costs,,,,"1-6,10-11, 15-25,",,, ,,,,,,"30-39, 50-53",5,11,9 ,,Reclassifications,,,,"1-6,10-11, 15-25,",,, ,,,,,,"30-39, 50-53",7,11,-9 ,,Adjustments,,,,"1-6,10-11, 15-25,",,, ,,,,,,"30-39, 50-53",9,11,-9 ,,Net expense for allocation,,,,"1-6,10-11, 15-25,",,, ,,,,,,"30-39, 50-53",10,11,-9 ,,Total,,,,100,1-10,11,-9 ,,,,,,,,, ,,,,,"WORKSHEETS A-1, A-2, & A-3",,,, ,,,,,,,,, ,,"Salaries, benefits & Contract Services",,,,"3-6,10-11, 15-25,",,, ,,,,,,"30-39, 50-53",1-8,11,-9 ,,,,,,"3-6,10-11, 15-25,",,, ,,Total,,,,"30-39, 50-53",9,11,9 ,,,,,,,,, ,,38-214,,,,,,,Rev. 8 ,,08-06,,,FORM CMS-1984-99,,,,3895 (Cont.) ,,ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99,,,,,,, ,,"TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS",,,,,,, ,,,,,,,,, ,,,,,,,,FIELD, ,,,,DESCRIPTION,,LINE(S),COLUMN(S),SIZE,USAGE ,,,,,,,,, ,,,,,WORKSHEET A-6,,,, ,,,,,,,,, ,,For each expense reclassification:,,,,,,, ,,,Explanation,,,1-35,0,36,X ,,,Increases:,,,,,, ,,,,Adjustment letter(s),,1-35,1,2,X ,,,,Worksheet A line number ,,1-35,3,6,9(3).99 ,,,,Reclassification salary amount,,1-35,4,11,9 ,,,,Reclassification other amount,,1-35,5,11,9 ,,,Decreases:,,,,,, ,,,,Worksheet A line number,,1-35,7,6,9(3).99 ,,,,Reclassification salary amount,,1-35,8,11,9 ,,,,Reclassification other amount,,1-35,9,11,9 ,,,Total,,,100,"4, 5, 8 & 9",11,9 ,,,,,,,,, ,,,,,WORKSHEET A-7,,,, ,,,,,,,,, ,,"For land, land improvements, buildings and fixtures, building",,,,,,, ,," improvements, fixed and movable equipment, and in total:",,,,,,, ,, Analysis of changes in capital asset balances,,,,,,, ,,,,Beginning balance,,1-9,1,11,9 ,,,,Purchases,,1-9,2,11,9 ,,,,Donations,,1-9,3,11,9 ,,,,Disposals and retirements,,1-9,5,11,9 ,,,,,,,,, ,,,,,WORKSHEET A-8,,,, ,,,,,,,,, ,,Description of adjustment,,,,8,0,36,X ,,Basis (A or B) *,,,,"1-2, 4-10, ",1,1,X ,,Amount *,,,,1-10,2,11,-9 ,,Worksheet A line number +,,,,"1-2, 4-10",4,6,9(3).99 ,,Total,,,,11,2,11,-9 ,,,,,,,,, ,,* These include subscripts of lines 1-2 and 4-10 requiring records for columns 1 and 2. These subscripts should occur ,,,,,,, ,, based on Worksheet A layout.,,,,,,, ,,"+ Do not include preprinted lines, i.e. lines 9-10. ",,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,WORKSHEET A-8-1,,,, ,,,,,,,,, ,,Part A - For costs incurred and adjustments required as a,,,,,,, ,, result of transactions with related organization(s):,,,,,,, ,,,,Worksheet A line number,,1-4,1,6,9(3).99 ,,,,Expense item(s),,1-4,3,36,X ,,,,Amount allowable in reimbursable cost,,1-4,4,11,9 ,,,,Amount included in Worksheet A,,1-4,5,11,9 ,,,,Total,,5,4-5,11,-9 ,,Part B - For each related organization:,,,,,,, ,,,,Type of interrelationship (A through G),,1-5,1,1,X ,,,,"If type is G, description of relationship must be",,,,, ,,,, included.,,1-5,0,36,X ,,,,Name of individual or partnership with interest,,,,, ,,,, in provider and related organization,,1-5,2,36,X ,,,,Percent of ownership of provider,,1-5,3,6,9(3).99 ,,,,Name of related organization,,1-5,4,36,X ,,,,Percent of ownership of related organization,,1-5,5,6,9(3).99 ,,,,Type of business,,1-5,6,15,X ,,,,,,,,, ,,,,,,,,, ,,,,,,,,, ,,Rev. 7,,,,,,,38-215 ,,3895 (Cont.),,,FORM CMS-1984-99,,,,08-06 ,,ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99,,,,,,, ,,"TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS",,,,,,, ,,,,,,,,, ,,,,,,,,FIELD, ,,,,DESCRIPTION,,LINE(S),COLUMN(S),SIZE,USAGE ,,,,,,,,, ,,,,, WORKSHEETS B-1 HEADINGS*,,,, ,,,,,,,,, ,,Column heading (cost center name),,,,1-3*,1-6,10,X ,,Statistical basis,,,,"4, 5*",1-6,10,X ,,,,,,,,, ,,,,,WORKSHEET B,,,, ,,,,,,,,, ,,Total adjustments after cost finding,,,,100,6,11,-9 ,,Costs after cost finding and post stepdown,,,,,,, ,, adjustments by department,,,,"10-11,",,, ,,,,,,"15-25, 30-39,",,, ,,,,,,50-53,7,11,-9 ,,Total costs after cost finding and post stepdown adjustments,,,,100,7,11,9 ,,,,,,,,, ,,*,Refer to Table 1 for specifications and Table 2 for the worksheet identifier for column headings. There may be up to five,,,,,, ,,,"type 2 records (3 for cost center name and 2 for the statistical basis) for each column. However, for any column which has",,,,,, ,,,"less than five type 2 record entries, blank records or the word ""blank"" is not required to maximize each column record count.",,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,WORKSHEET B-1,,,, ,,,,,,,,, ,,For each cost allocation using accumulated costs as the,,,,,,, ,," statistic, include a record containing an X.",,,,0,6,1,X ,,All cost allocation statistics,,,,"1-6, 10-11,",,, ,,,,,,"15-25, 30-39,",,, ,,,,,,50-53,1-6*,11,9 ,,Reconciliation,,,,"1-6, 10-11,",,, ,,,,,,"15-25, 30-39,",,, ,,,,,,50-53,6A,11,-9 ,,,,,,,,, ,,Total cost to be Allocated,,,,100,1-6,11,9 ,,,,,,,,, ,,*," In each column using accumulated costs as the statistical basis for allocating costs, identify each cost center which is",,,,,, ,,, to receive no allocation with a negative 1 (-1) placed in the accumulated cost column. Providers may elect to indicate,,,,,, ,,," total accumulated cost as a negative amount in the reconciliation column. However, there should never be entries in",,,,,, ,,, both the reconciliation column and accumulated column simultaneously on the same line. For those cost centers which,,,,,, ,,," are to receive partial allocation of costs, provide only the cost to be excluded from the statistic as a negative amount on",,,,,, ,,, the appropriate line in the reconciliation column. ,,,,,, ,,," If line 6 is fragmented, line 6 must be deleted and subscripts of line 6 must be used.",,,,,, ,,,,,,,,, ,,+, Include any column which uses accumulated cost as it basis for allocation.,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,WORKSHEET D,,,, ,,,,,,,,, ,,"Total cost (Worksheet B, line 100, col 7, less line 53, col. 7)",,,,1,4,11,-9 ,,"Total Unduplicated Days (Worksheet S-1, line 12, col. 6)",,,,2,4,11,9 ,,Average cost per diem (line 1 divided by line 2),,,,3,4,11,9(8).99 ,,"Unduplicated Medicare Days (Worksheet S-1, line 12, col.1)",,,,4,1,11,9 ,,Average Medicare cost (line 3 times line 4),,,,5,1,11,9 ,,"Unduplicated Medicaid Days (Worksheet S-1, line 12, col. 2)",,,,6,2,11,9 ,,Average Medicaid cost (line 3 times line 6),,,,7,2,11,9 ,,"Unduplicated SNF days (Worksheet S-1, line 12, col. 3)",,,,8,1,11,9 ,,Average SNF cost (line 3 times line 8),,,,9,1,11,9 ,,"Unduplicated NF days (Worksheet S-1, line 12, col. 4)",,,,10,2,11,9 ,,Average NF cost (line 3 times line 10),,,,11,2,11,9 ,,"Other Unduplicated days (Worksheet S-1, line 12, col. 5)",,,,12,3,11,9 ,,Average NF cost (line 3 times line 12),,,,13,3,11,9 ,,,,,,,,, ,,38-216,,,,,,,Rev. 7 ,,09-11,,,FORM CMS-1984-99,,,,3895 (Cont.) ,,ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99,,,,,,, ,,"TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS",,,,,,, ,,,,,,,,, ,,,,,,,,FIELD, ,,,,DESCRIPTION,,LINE(S),COLUMN(S),SIZE,USAGE ,,,,,,,,, ,,,,,WORKSHEET G,,,, ,,,,,,,,, ,,For the hospice:,,,,,,, ,,Text as needed for blank lines,,,,48,0,36,X ,,Balance sheet accounts,,,,"1-10, 12-26, 28-31,",,, ,,,,,,"34-41, 43-48, 51",1,11,-9 ,,For hospices or hospices using fund accounting:,,,,,,, ,,,Specific purpose fund account balances,,,"1-10, 12-26, 28-31,",,, ,,,,,,"34-38,40-41, 43-48,",,, ,,,,,,52,2,11,-9 ,,,Endowment fund account balances,,,"1-10, 12-26, 28-31,",,, ,,,,,,"34-38,40-41, 43-48,",,, ,,,,,,53-55,3,11,-9 ,,,Plant fund account balances,,,"1-10, 12-26, 28-31,",,, ,,,,,,"34-38,40-41, 43-48,",,, ,,,,,,56-57,4,11,-9 ,,Total Assets,,,,33,1-4,11,-9 ,,Total Liabilities and Fund Balance,,,,59,1-4,11,-9 ,,,,,,,,, ,,NOTE: Accumulated Depreciation lines will always be positive numbers unless otherwise specified.,,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,WORKSHEET G-1,,,, ,,,,,,,,, ,,For hospices using fund accounting:,,,,,,, ,,Text as needed for blank lines,,,,"4-9, 12-17",0,36,X ,,,Beginning fund balances,,,1,1-4,11,-9 ,,,Additions and reductions to ,,,,,, ,,, beginning fund balances,,,"4-9, 12-17",1-4,11,-9 ,,,,,,,,, ,,,,,,,,, ,,,,,WORKSHEET G-2,,,, ,,,,,,,,, ,,Part I:,,,,,,, ,,Skilled nursing facility based,,,,1,1,11,9 ,,Nursing facility based,,,,2,1,11,9 ,,Home care,,,,3,1,11,9 ,,Other (see instructions),,,,4,1,11,9 ,,State Medicaid room and board,,,,5,1,11,9 ,,Total general inpatient revenue,,,,6,1,11,9 ,,,,,,,,, ,,Part II:,,,,,,, ,,Text as needed for blank lines,,,,"2-7, 9-13",0,36,X ,,Increases to operating expenses reported on Worksheet A,,,,2-7,1,11,9 ,,Decreases to operating expenses reported on Worksheet A,,,,9-13,1,11,9 ,,Total operating expenses,,,,15,2,11,9 ,,Net income/Loss,,,,16,2,11,-9 ,,,,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,,,,, ,,Rev. 9,,,,,,,38-217